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y%W <br />.: �'V 3 1 ;S a S/6 � 'l 9 � �5 � $ i�. $ .. �� $ � i � K� � 8,D ♦ �,L 5 £ R i7 �" <br />SAN JOAQUIN COUNTY <br />Telephone- (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be retained to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />GH%4t, Hor+ <br />f, L< c <br />e. L, L <br />X1,5374 <br />TANK ID #39 - �( = y TANK SIZE: It i� �' PREVIOUS TANK CONTENTS: <br />i <br />SECTION 2 - To be filled out by tank removal contractor: <br />4.. _ t <br />Tank Removal Contractor: y t 1tj;� E' t �S <br />J <br />it j )c S A1t� t JA,(: , City: N i.(C Zip: 15-3 l <br />Address- 1 <br />Phone #: j`7 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address- j� � Y'l,-Cayitm Ayc, _City: it Lt Zip: �J '� <br />Phone #: '- -15 <br />L <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. � p <br />Name: <br />1 l y� L� Ir y1 Title: (" Y SI ("l F r Signature: Date1U �_- Qp-_ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name:'��,5��'Ltc <br />Address: ! Z <br />?( <br />Phone #: ( <br />City: !4,''1i(;C1'C_ Zip: <br />EH 23 046 (Revised 12/31/07) 10 <br />